2017 Consensus Guidelines on the Approach to Syncope in Adults and Children

by Joseph Esherick, M.D., FAAFP, FHM

Key Recommendations

1). Initial evaluation

  • Conduct physical exam, history (with careful attention to factors in Tables 1 & 2) and resting electrocardiogram (ECG) to identify a possible cause (see Tables 2 & 3).

2). Disposition from the emergency department (ED)

  • Hospital admission is recommended for patients with serious medical conditions that might be relevant to the identified cause of syncope.
  • For admitted patients with syncope suspected to be of cardiac etiology, admit to a telemetry unit for continuous cardiac monitoring.
  • Patients with presumptive reflex-mediated syncope (i.e., situational syncope) may be managed as outpatients if they do not have serious medical conditions.
  • ED observation units are appropriate for patients at intermediate risk who have an unclear cause of syncope.

3). Testing

  • Only if the initial clinical evaluation does not reveal an etiology, targeted blood tests may be reasonable (e.g., CBCD, CMP, cardiac enzymes).
  • For selected patients with syncope suspected to be due to cardiovascular causes, certain tests may be useful, including the following:
    • For structural heart disease: transthoracic echocardiography
    • For cardiac etiology: cardiac computed tomography or magnetic resonance imaging
    • For syncope during exertion: echocardiogram and exercise stress testing
    • For arrhythmia: electrophysiologic studies

4) DMV Reporting

  • All cases of syncope requiring hospitalization should be reported to the DMV as they constitute an example of a “lapse in consciousness.”

 

Table 1:  Risk Factors for Syncope Requiring Hospitalization

Male sex

Older age (>60 y)

No prodrome

Palpitations preceding loss of consciousness

Exertional syncope

Cancer

Structural heart disease

Heart failure

Cerebrovascular disease

Family history of Sudden Cardiac Death

Diabetes mellitus

Trauma

 

Table 2:  Physical Examination or Laboratory Investigation

Abnormal ECG (e.g., pathologic Q waves, non-sinus rhythm or AV block)

Evidence of bleeding

Persistent abnormal vital signs (especially SBP<90 and HR<50 or >140)

Elevated troponin I or troponin T

 

Table 3:  Examples of Serious Medical Conditions That Might Warrant Consideration of Further Evaluation and Therapy in a Hospital Setting

 

Cardiac Arrhythmic Conditions

  • Sustained or symptomatic Ventricular tachycardia
  • Symptomatic conduction system disease or Mobitz II or third-degree heart block
  • Symptomatic bradycardia or sinus pauses not related to neurally mediated syncope
  • Symptomatic Supraventricular tachycardia
  • Pacemaker/ICD malfunction
  • Inheritable cardiovascular conditions predisposing to arrhythmias

 

Cardiac or Vascular Nonarrhythmic Conditions

  • Cardiac ischemia
  • Severe aortic stenosis
  • Cardiac tamponade
  • Hypertrophic cardiomyopathy
  • Severe prosthetic valve dysfunction
  • Pulmonary embolism
  • Aortic dissection
  • Acute Heart failure
  • Moderate-to-severe Left Ventricular dysfunction

 

Noncardiac Conditions

  • Severe anemia/gastrointestinal bleeding
  • Major traumatic injury due to syncope
  • Persistent vital sign abnormalities (especially SBP<90 and HR<50 or >140)

 syncope in adult at hospital

Shen W-K et al. ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines, and the Heart Rhythm Society. Circulation 2017 March 9